ABSTRACT
Background: Many EP procedures are moving from the hospital to the ambulatory surgery center (ASC) outpatient setting. The COVID-19 pandemic and the CMS Hospitals Without Walls (HWW) program has been an impetus in accelerating this transition. Anesthesia provider perioperative management is critical in facilitating safe procedures with rapid, same-day discharge. Our EP-dedicated 2-OR ASC completed more than 3,000 procedures and more than 500 left-sided ablations utilizing general anesthesia with endotracheal intubation with same-day discharge. To our knowledge, this experience is unique within an ASC setting in both volume and complexity. Objective(s): We present our comprehensive anesthesia strategy and lessons learned to facilitate safe, efficient procedures and discharge in an EP ASC. Method(s): A nurse anesthesiologist with more than a decade of EP-dedicated experience developed and taught a perioperative anesthesia strategy to facilitate high volume, safe and quick discharge care. Fundamental to this is the avoidance of opioids and benzodiazepines whenever possible. Propofol or general anesthesia with sevoflurane and complete reversal with sugammadex allow for quick recovery. Mandatory video laryngoscope utilization minimizes airway trauma, while liberal antiemetic use eliminates most nausea. All femoral access is device closed. Positive inotropes are used liberally during anesthetic to avoid heart failure. The goal is to deliver all patients to PACU on room air with stable hemodynamics. Anesthesia providers manage the preop and recovery area. Result(s): More than 90% of all patients undergoing general anesthesia and heparinization for left-atrial ablation were discharged home in under 3 hours. Nearly all procedures not requiring femoral access were discharged within 30-60 minutes. High procedure volumes with efficiencies far exceeding our in-hospital experience were thus facilitated with improved patient safety. Since HWW began, five patients have required transfer to the hospital without any deaths. All others were discharged same day. Conclusion(s): We suggest that a dedicated anesthesia team with a tailored perioperative anesthesia plan facilitates performing nearly all EP-related surgical procedures in an ASC. This success is facilitated by appropriate patient selection, preoperative evaluation, intraoperative care prioritizing quick return to baseline, and end-to-end anesthesia perioperative management. We believe this type of anesthesia management is critical to the transition of EP procedures to ASCs.Copyright © 2023
ABSTRACT
Cold agglutinin disease(CAD) is an autoimmune disease that occurs against erythrocyte antigens. It is usually idiopathic, but some infections can also be a trigger. CAD becomes active in the peripheral circulation at lower temperatures more easily when exposed to cold, causing hemolysis or agglutination. In this article, the management of a coronary bypass case with CA formation in intraoperative period is presented. A 46-year-old diabetic and hypertensive male patient had COVID-19 2 months ago. Cardiopulmonary bypass(CPB) was initiated with adequate heparinization, and the patient was cooled to 32degreeC. It was noticed that there were clots in the cardioplegia delivery line(+1degreeC). Agglutinations were observed in the autologous blood of the patient whose ACT values were normal. After CPB, the operation was completed without any problems and the patient was discharged on the 5th day with recovery. A diagnosis of CAD was made with the results of peripheral smear and immunologic tests. Determination of antibody concentration and thermal amplitude in the preoperative period in patients with CAD is very important. While preparing such patients for surgery, heating of room, patient, fluids, planning of normothermic CPB, and using warm cardioplegia are required. The relationship between CAD and COVID has started to take place in the literature. The patient we presented had a COVID 2 months ago, cold agglutinin may have been induced by COVID or may have arisen idiopathic. Considering that many people may have had a COVID nowadays, care should be taken especially in the perioperative period of cardiac surgery.Copyright © Telif hakki 2022 Gogus-Kalp-Damar Anestezi ve Yogun Bakim Dernegi Dergisi - Available online at www.gkdaybd.org.
ABSTRACT
Cold agglutinin disease(CAD) is an autoimmune disease that occurs against erythrocyte antigens. It is usually idiopathic, but some infections can also be a trigger. CAD becomes active in the peripheral circulation at lower temperatures more easily when exposed to cold, causing hemolysis or agglutination. In this article, the management of a coronary bypass case with CA formation in intraoperative period is presented. A 46-year-old diabetic and hypertensive male patient had COVID-19 2 months ago. Cardiopulmonary bypass(CPB) was initiated with adequate heparinization, and the patient was cooled to 32degreeC. It was noticed that there were clots in the cardioplegia delivery line(+1degreeC). Agglutinations were observed in the autologous blood of the patient whose ACT values were normal. After CPB, the operation was completed without any problems and the patient was discharged on the 5th day with recovery. A diagnosis of CAD was made with the results of peripheral smear and immunologic tests. Determination of antibody concentration and thermal amplitude in the preoperative period in patients with CAD is very important. While preparing such patients for surgery, heating of room, patient, fluids, planning of normothermic CPB, and using warm cardioplegia are required. The relationship between CAD and COVID has started to take place in the literature. The patient we presented had a COVID 2 months ago, cold agglutinin may have been induced by COVID or may have arisen idiopathic. Considering that many people may have had a COVID nowadays, care should be taken especially in the perioperative period of cardiac surgery.Copyright © Telif hakki 2022 Gogus-Kalp-Damar Anestezi ve Yogun Bakim Dernegi Dergisi - Available online at www.gkdaybd.org.
ABSTRACT
The infection with SARS-CoV-2 during pregnancy is associated with significant risks for the mother and also the fetus is at risk due to preterm birth, intrauterine growth restriction, and,-in some cases-, intrauterine fetal death. Despite the fact that IgG-antibodies can be transmitted from the mother to the fetus thrombosis of the placenta may lead to complications. Depending on the course of the disease, the risk of thrombosis for the pregnant woman is increased as well. Therefore, in some cases, heparinization is recommended. Vaccination against COVID-19 protects the mother from severe disease courses as well as from infection-related pregnancy complications. Thus, every pregnant woman should be informed about the option of vaccination even during pregnancy. According to the STIKO, the best time for vaccination is throughout the second trimenon.Copyright © 2022, The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.
ABSTRACT
Background: In the literature there has been minimal discussion of heparin resistance with regards to the post-COVID syndrome. Since the COVID pandemic began, patients with COVID were suffering complications from VTE that suggested the presence of a hypercoagulable state. Generally this hypercoagulable state is described through the use of thromboelastogram six (TEG6) with a short R time, wide alpha angle and a very large amplitude. Aim(s): In this case we were using the TEG6 as a guide for heparin therapy by following the CK-R time compared to the CKH-R time (with heparinase). We observed no bleeding or clotting events. While the patient was on ECMO, there were no changes in the delta-P and the circuit was not replced during his clinical course. Additionally, he required no blood transfusions during this time. Method(s): An observational analysis of TEG6 in COVID-19 ECMO patient while using an anti-Xa heparin based protocol for therapeutic heparin therapy. Result(s): On the initial TEG6, there was a significantly prolonged R time that was partially corrected with heparinase -with heparin dosing of 24 IU/kg/h (65,000 IU/day), see figure one. With the prolonged R time, heparin was descalated to 16 IU/kg/h and the coagulation profile was resent, see figure two. Additionally, the TEG6 MA remained elevated -consistent with the hypercoagulable post-COVID syndrome. This occurred in the setting of a normal anti-thrombin three level and platelet counts. Conclusion(s): Through the use of TEG6, we were able to better characterize his coagulation profile and we were able to deescalate his dosing of heparin using the CK and CKH-R time comparison. We propose using TEG6 to redefine heparin resistance in the post-COVID syndrome of hypercoagulopathy, as older modalities may not be accurately reflecting this modern pathology. (Figure Presented).
ABSTRACT
Introduction: At the outset of the COVID-19 pandemic we observed an unacceptably high incidence of intracranial hemorrhage during VV ECMO support for COVID-19 related respiratory failure. The relationship between PTT and Anti-Xa values was explored by pharmacy and facility ECMO leadership, and found COVID patients to have elevated Anti-Xa levels at prescribed PTT levels. Method(s): We retrospectively analyzed data of 38 adult COVID-19 VV ECMO patients at Massachusetts General Hospital from March 18, 2020 to February 1, 2022 for incidence of ICH before and after anticoagulation protocol was changed on May 12th 2020. Result(s): Prior to change in practice, ICH was present in 33% (n = 4) of all COVID+ VV ECMO runs (n = 12). ICH was present in 57% of all deaths (n = 7) during this period. On May 12th 2020, after a pharmacy review, along with regional/international meetings among many ECMO centers MGH initiated a new protocol for COVID-19 positive ECMO patients targeting an Anti-Xa range of 0.15-0.29 with heparin titration. After this change, there were a subsequent 26 VV ECMO runs meeting the criteria for this study. ICH was present in only 3.8 % of patients (n = 1). And was present 6.3% (n = 1) of all deaths (n = 16). Conclusion(s): Anti Xa guided anticoagulation strategy resulted in a 88% decrease in the incidence of ICH in COVID-19 positive VV ECMO patients during the time of this retrospective analysis and proved a safe alternative to PTT guided heparin therapy.
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Background: The Covid-19 pandemic has been raging for more than a year in a pandemic mode. Since then, many questions have been raised regarding the management of patients with rheumatic diseases (RD). In this context, the maintenance therapy of conventional, biologic and targeted synthetic disease-modifying antirheumatic drugs (Cs DMARDs, bDMARDs and tsDMARDs respectively) during the Covid-19 infection remains a subject of debate given their immuno-suppressive effects as well as their potential generation of lung fbrosis. While the EULAR 2020 guidelines emphasize that discontinuation or maintenance should be discussed on a case-by-case basis, the ACR guidelines advocate discontinuation of all therapies except for the anti-interleukin-6 [1,2]. Objectives: The objective of our work was to report our real-life experience of therapeutic maintenance during the covid-19 pandemic. Methods: We conducted a cross-sectional study of patients with RD: rheumatoid arthritis (RA) and spondyloarthritis (SpA) recruited from the rheumatology department of the Kassab Institute of Orthopedics. All the patients were asked to complete a questionnaire about their disease management in the era of the Covid-19. The questionnaire included sociodemographic data, treatment modalities, as well as data related to the infection with the Covid-19 (severe forms defned by the need for oxygen therapy or hospitalization), and changes in treatment during the infection. Results: The study included 102 patients with RA (65.3%) and SpA (34.7%). The mean age was 52.4 ± 13 [19-77] years. There was a female predominance with a sex ratio of 0.4. The mean duration of the disease was 7. 8 ± 5 years [1-35]. Fifteen percent of patients were on corticosteroids with a mean dose of 6.7±4.5 mg/L [2-20] of prednisone equivalent. A CsDMARD was prescribed alone in 36.3% of cases and combined with a biologic in 18% of cases. A Covid-19 infection was occurred at least once in 25.5% of cases, of which 19.2% had a severe form (hospitalization (15.4%), oxygen therapy (19.2%)). No deaths were observed. The treatments received during the covid-19 infection were: corticosteroids (n=5), heparin therapy (n=6) and antibiotic therapy (n=10). No patient tapered treatment dosage of DMARDs but discontinuation was reported by 4 patients with a mean time between discontinuation and resumption of 2.1 ± 2 months [0.5-5 months]. The cessation of the treatment was dictated by the treating physician in 2 cases and involved csDMARD in 3 cases (Methotrexate (n=2), Lefunomide (n=1)) and biologics in only one patient. There were no cases of clinical pulmonary worsening upon resumption of the treatments. We found no statistically signifcant association between severe forms of the infection and the type of RD (p=0.925), as well as the presence of comorbidities (p=0.825). Similarly, the presence of severe forms was not associated with the use of long-term NSAIDs (p=0.29), corticosteroids (p=0.85), or biological treatment (p=0.7). However, maintenance therapy was signifcantly associated with a lower risk of severe forms (p=0.013). Conclusion: Our work showed that the maintenance of conventional treatment during Covid-19 infection was associated with a lower risk of severe forms. Our results, along with those of other studies in the literature, support the maintenance of antirheumatic treatments.
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Background: As vaccinations against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continue worldwide, increased rates of venous thrombotic events, mainly as cerebral venous sinus thrombosis (CVST), have been reported following adenovirus vector-based SARS-CoV-2 vaccination. However, few reports have described the occurrence of venous thrombosis after messenger RNA (mRNA)-based vaccination. Here, we describe a case of CVST after a first dose of mRNA-based vaccination that was treated with emergent endovascular mechanical thrombectomy and systemic heparinization.Case Description.A 43-year-old, previously healthy man suffered severe headache and partial seizures affecting the left arm 4 days after receiving the first dose of an mRNA-based SARS-CoV-2 vaccination (FC3661; Pfizer/BioNTech). Computed tomography showed intraparenchymal hemorrhage. Seven days after vaccination, symptoms worsened and he was transferred to our tertiary hospital. Magnetic resonance venography revealed CVST with occlusion of the superior sagittal sinus (SSS) and right transverse sinus (TS). Since no findings suggested thrombosis with thrombocytopenia syndrome, the patient underwent systemic heparinization and emergent mechanical thrombectomy with balloon transluminal angioplasty, a stent retriever and an aspiration catheter. Complete SSS and right TS recanalization were achieved and the patient was discharged without neurological deficits. Conclusion: Clinicians should be aware that apparently healthy individuals with no risk factors can develop CVST after receiving an mRNA-based vaccine and appropriate treatment including EMT need to be performed immediately.(228 words).
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Introduction: MIS-C is a rare complication of COVID-19 in children. The estimated incidence of laboratory-confirmed SARS-CoV-2 infection in individuals<21 years old was 322 per 100,000 and the incidence of MIS-C was 2 per 100,000. The initial reports of MIS-C emerged from the United Kingdom in April 2020. Since then, there have been reports of similarly affectedchildrenin otherparts of theworld, including Europe, Canada, the United States, and SouthAfrica. Whilemany children with MIS-C meet criteria for complete or incomplete Kawasaki disease (KD), the epidemiology differs from that of classic KD. This report is about the MIS-C children seen at a tertiary center in Istanbul-Turkey. Weaimed to determine prognosis by means of cardiovascular and arrhythmia assessment. Methods: We evaluated thirty-five MIS-C children who were hospitalized with COVID-19 infections through laboratory findings, electrocardiography (ECG), and transthoracic echocardiography (TTE) (March-December 2020). Patients were evaluated by the diagnostic criterias of both CDC and WHO. The differences were noted. On ECG, the risk of arrhythmia was observed by the evaluation of depolarization and repolarization parameters (such as Tp-Te interval, Tp-Te/QTc, Tp-Te/QT ratio) and by TTE, cardiac ventricle systolic and diastolic functions employing ejection fraction, fractional shortening, and Doppler parameters were studied. All coronary arteries were evaluated with TTE. Results: Mean age of the patients were 15.5±5.7 years (23 boys, 12 girls). We observed significantly increased levels fibrinogen, D-Dimer, LDH, ferritin, and IL-6 levels. There was significant changes by means of TpTe, Tp-Te/QT, andTp-Te/QTconECG.19patients hadnocoronary artery involvement, while 16 had, and three of them also had thrombosis at the time of prognosis. Patients were treated with IVIG, Metilprednisolon, Pulse steroid, asetylsalicylic acid(anti-inflammatory and anti-thrombotic doses), clexane, and heparinization that depends on the course of the disease. Ten patients had inotropic support. Conclusions: The thought that children are less affected by COVID-19 may be a misconception after the diagnosis of MISC. There are a lot of unknowns about COVID-19 and MIS-C. Therefore, one should be alert while evaluating a child with COVID-19 infection, because of sudden clinical detoriation of MIS-C patients.
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Purpose: We want to evaluate clinical, laboratory profiles and intra-hospital outcome in patients with acute PE treated in intensive care unit in the period of COVID-19 pandemic. Methods: This is a single center, retrospective cohort study of patients with confirmed acute PE admitted in Intensive Cardiac Care Unit of a tertiary level university hospital between January and December 2020. Detailed history, risk factors, laboratory parameters and treatment strategy based on patient risk were assessed. All patients underwent 2-dimensional echocardiography, lower limb venous Doppler and CT pulmonary angiography (CTPA). sPESI score and intra-hospital outcomes were evaluated in all patients. Nasopharyngeal smear and realtime reverse transcriptase-polymerase chain reaction (RT-PCR) assay was performed in order to confirm COVID-19 infection. Results: We studied 47 patients with acute PE treated in our ICU, with mean age 58.6 ± 19.4 years. Eight patients (17%) had massive PE (central thrombus) and 39 (83%) had sub massive PE (subsegmental thrombus) confirmed by CTPA. Six patients (12,7%) had history of deep vein thrombosis (DVT), 3 patients (6,3%) had history of prior PE, 4 patients (8,5%) were operated within 3 months, 7 patients (14,8%) had history of malignancy, 24 patient's had increased body weight and obesity (51%). Twelve patients (25,5%) were tested for COVID 19 with real-time reverse transcriptase-polymerase chain reaction (RT-PCR) assay, and 3 come positive (12.5%). Eight patients were high risk with shock (17%), intermediate high risk were 29 patients (61.7%) and intermediate low risk were 10 patients (21.3%). sPESI score was >1 in all 47 patients. Abnormal RV function with PAH was found in 32 patients (68%). Five high risk, unstable patients died within 72 hours of admission, resulting in an overall ICU mortality rate of 10,6% and 62.5% mortality rate in patients with cardiogenic shock. Patients with PE and COVID-19 had significantly higher D-dimer and hs-Troponin I levels comparing to the patients with patients negative for COVID-19. Multivariate logistic regression analysis showed thrombolytic therapy OR 2.145 (95% CI: 1.105-4,512), D-Dimers >4.500 ng/ml OR 1.893 (95% CI: 0.932-3.241), high risk PE OR 3.98 (95% CI: 1.396-5.641) and acute renal failure OR 2.421 (95% CI: 1.105-4.762) as independent mortality predictors. Eight patients have been treated with fibrinolysis (t-PA), and 39 patients with Heparin therapy. 40 survived patients were discharged with NOAC treatment (95,2%). Conclusions: Pulmonary embolism cardiology clinic ICU admission in the period of COVID-19 pandemic decreased, with increase of PE severity, patients risk and mortality rate. Thrombolytic therapy, D-Dimers >4.500 ng/ml, high risk PE and acute renal failure were independent mortality predictors. Thrombolysis was successful treatment for high risk patients with low bleeding risk.
ABSTRACT
Background: Atrial fibrillation (AF) is a widespread cause of prothrombotic state leading to long-term anticoagulant therapy. Literature describes coagulopathy as a key pathogenic mechanism of COVID-19 disease. Thus, antithrombotic therapy management is still a therapeutic challenge. During hospitalization, changing oral anticoagulant (OAC) therapies into subcutaneous heparin is common in daily clinical practice. Purpose: The primary endpoint of this study is to analyze the impact of AF in mortality within 30 day since admission of COVID-19 patients. The secondary endpoint is to analyze the impact of the anticoagulant therapy strategy (therapeutic dose of subcutaneous heparin vs. OAC) in 30-day mortality of hospitalized COVID-19 patients with AF. Methods: A total of 1001 consecutive patients hospitalized in our centre between 22nd August and 9th January 2021 with a confirmed microbiological diagnosis of COVID-19 by PCR were prospectively included. Of them, 134 had a previous diagnose of AF (13.5%). Cox regression analysis was performed to assess the impact of AF and the choice of anticoagulant therapy in 30-day mortality after adjusting for comorbidity (Charlson Comorbidity Index). Results: After adjusting for comorbidities, AF was not independently associated with a higher 30-day mortality in patients hospitalized due to COVID-19 infection (HR 1.04, CI 0.77-1.43, p=0.760). In the group of patients with AF, changing OAC to heparin therapy was not associated with an improved prognosis (HR 0.85, CI 95% 0.46-1.56, p=0.604). Conclusions: AF is not an independent prognostic factor in COVID-19 hospitalized patients. In hospitalized COVID-19 patients with AF, changing OAC to heparin therapy is not related to an improved prognosis.